SOUTH AFRICAN GLAUCOMA SOCIETY MEETING 2014

 

Spier played host again to our annual Glaucoma conference..what a magnificent setting for an academic meeting.

We had some wonderful local and international guest speakers to tell us about new and innovative technologies, and recap some of the most important aspects of medical and surgical glaucoma management.

 

We were even entertained by a South African legend comedian…Mr Robinowitz himself…trust myself and my wife to have front row seats for his show…we took some heavy artillery shells from the stage, needless to say..

Below are a few take home points from the meeting:

Prof D. Meyer:

  • IV Paracetamol has shown a link to decreased IOP-watch this space!!!

 

Nicky Welsh:

  • Current thinking is to discard C:D ratio
  • Clinically we tend to overestimate rim width.
  • We need to integrate SD OCT into practice.
  • OCT has good sensitivity in early to moderate glaucoma and OHT
  • we need 3 visual fields per annum to document progression.

Grant McLaren:

  • Ocular perfusion pressure is a glaucoma risk factor
  • NB to measure patients blood pressure!
  • Low BP during sleep is a strong predictor for progression. The bigger the dips in BP, the greater the risk.
  • Visual field changes of >0.5 dB per year are indicative of progression-3 fields per year are necessary.
  • SLT is very effective for steroid induced glaucoma.
  • ALT carries a high risk of IOP spikes.
  • Do not treat normal tension glaucoma until you document progression.
  • Spontaneous venous pulsation is very NB-if the vein pulsates spontaneously, it is a good sign.

Ingeborg Stalmans: Trabeculectomy and post op management

  • 1 week post op hypertony: massage x2
  • Then only consider suture lysis with Hoskins lens and Argon laser.
  • Do gonioscopy prior to massage to ensure there is nothing blocking your ostium.
  • Hypertony with a functional bleb usually indicates residual viscoelastic in the eye-leave it.
  • Blood in the bleb/AC-do gonioscopy. If there is no blood, do subconj TPA
  • For specifically blood in AC inject TPA intracamarally.
  • If there is fresh iris incarceration in the ostium, use pilocarpine.
  • Hypertony with functional bleb at 2 weeks is likely steroid response.
  • With malignant glaucoma, the IOP is usually 30-40mmHg.
  • Progressive increase in IOP and shallowing of AC, think malignant glaucoma.
  • Treatment of this is Atropine, Diamox, Mannitol, YAG hyaloidotomy. If pseudophakic then vitrectomy and zonulectomy can be considered.
  • Diode laser cyclodestruction as last resort.
  • Bleb needling is used for an encapsulated bleb.
  • Bleb revision is done when you have a failed bleb.
  • Ischemic blebs related to MMC use can result in sweating blebs.
  • Do not needle a cystic bleb!!
  • Needling technique: Iopidine, BNX, Betadine, needling knife supplied by Visitec.
  • Never do a needling revision at the slit lamp-always got to OT.

Hypotony:

  • Wound leak? Check Seidel test with high concentration fluorescin.
  • Be alert for wound leakage if you have hypotony with flat bleb. Check the bleb and sutures in the 1st month if the patient complains of epiphora.
  • Conservative management includes:
  • ¬†Patching.
  • Low dose Diamox 125mg bd, or Diamox/Timolol topical combination.
  • Therapeutic soft contact lens.
  • Taper steroids to allow fibrosis.
  • Always continue antibiotics!!

 

  • Large leaks along sutures need closure-fibrin glue/cyanoacrylate/autologous fibrin glue.
  • If at 1 week post op there is low IOP, there is likely overfiltration. If no choroidals, wait.
  • If shallow AC, macular folds, choroidals, then use: Atropine, Megasoft CL,decrease steroids,inject viscoelastic into the AC, compression sutures(Pfeiffer), and lastly trab revision if necessary.
  • Dr Stalmans leaves an air bubble in the AC after trabs.
  • This gives her a good indication as to the filtration: IF half is out on day 1, then there is good filtration;if all out then overfiltration present;if a full bubble still present then there is no filtration.
  • Pfeiffer suture: transconjunctival 10.0 nylon through the scleral flap and out again. You can leave in this position-it eventually erodes underneath the conjunctiva with no problems.
  • With regards overfiltration: beware of IOP rise. If this happens then think of a choroidal Hg or malignant glaucoma.
  • Choroidal haematomas must be drained at 7-10 days if no resolution.
  • In the case of early discomfort, talk to the patient.This is normal.
  • If you have an ischemic bleb, excise with conjunctival advancement. Always make sure you have donor sclera to cover the potential scleral defect.
  • Stop Aspirin 3 weeks prior to trab surgery.
  • Stop Flomax and Warfarin 10 days prior to surgery.
  • Try to get the patient off anti-inflammatory drugs prior to surgery too.
  • Only once you are happy post-op that the patient will not need needling, then you can start the above therapies again.
  • FML QID prior to trab has been shown to improve outcomes.
  • Surgical tip: Fill AC 1/3 to 1/2 with viscoelastic prior to surgery. You can leave this in the AC afterwards.
  • A Moorfields study showed that the most sensitive predictor for bleb failure is vascularization-that is why subconj Avastin is so effective.
  • Avastin also has a complimentary effect to MMC and allows us to reduce the dosage.
  • How od we manage patients despite a low IOP and progression??
  • Remember that OPP=BP-IOP
  • Therefore we need to look at: Holter ECG for cardiac arythmias, Sleep apnoea tests, duplex dopplers of carotids for stenosis and BP monitoring for dips.
  • Remember BP is lowest in the morning and highest at night. This is when perfusion pressure is lowest.
  • Avoid medication with anti-cholinergic activity: Benzodiazepines, Parkinsons drugs, Anti-depressants-they may cause orthostatic hypotension.

 

So all in all, it was a fantastic experience as most of our conferences seem to be…

 

On the glaucoma horizon there is exciting new minimally invasive surgery coming to the fore….WATCH THIS SPACE!!